Transient Hiatal Separation During Straight Leg Raise Can Predict Reflux Burden in Gastroesophageal Reflux Disease Patients With Ineffective Esophageal Motility

Abstract

Background/AimsStraight leg raise (SLR) can be utilized to evaluate the integrity of the esophagogastric junction during high-resolution manometry (HRM). We aim to assess the value of transient hiatal separation during SLR in symptomatic reflux patients. MethodsConsecutive reflux patients undergoing esophageal HRM and pH monitoring were included. Transient hiatal separation was defined by a ≥ 1 cm separation between the lower esophageal sphincter and crural diaphragm during SLR. We compared esophageal motor patterns and reflux monitoring parameters between patients with normal, transiently abnormal and consistently abnormal esophagogastric junction morphology during SLR. ResultsOf 85 (56.3% female, mean age: 46.7 ± 12.3 years) completed SLR, esophagogastric junction morphology was normal in 31 (36.5%), transient hiatal separation in 19 (22.3%), and consistently hiatal hernia in 35 (41.2%). The values of total acid exposure time (P = 0.016), longest acid reflux episodes (P = 0.024), and DeMeester scores (P = 0.016) were higher in hiatal hernia compared to patients with non-transient hiatal separation, but there were no differences between those with and without transient hiatal separation. Within ineffective esophageal motility, the presence of transient hiatal separation during SLR significantly associated with a higher total acid exposure time (P = 0.014), higher DeMeester scores (P = 0.019), higher total acid reflux events (P = 0.037), and higher longest acid reflux episodes (P = 0.006). ConclusionOur work suggests that SLR may have value as a provocative test during HRM, and future outcome studies are warranted to elucidate the clinical relevance of motor abnormalities depicted from SLR.

Proximal Gastric Pressurization After Sleeve Gastrectomy Associates With Gastroesophageal Reflux

“…decline in trans-EGJ gradient) reliably associated with pathologic AET in single-center (9) and multicenter studies (11). Increase in intra-abdominal pressure with SLR has also been demonstrated to promote transient hiatus herniation, leading to increased esophageal reflux burden (22). Our findings validate the concepts explored by these early studies and suggest that increased IGP in SG is associated with higher reflux burden (19), likely by reducing the trans-EGJ pressure gradient when the EGJ is also disrupted.…”

Intermittent Hiatus Hernia on High-Resolution Manometry Associates With Abnormal Reflux Burden Similar to Persistent Hiatus Hernia

“…The longer Chicago Classification version 4.0 protocol with position changes could enhance intermittent LES-CD separation. In fact, increasing intra-abdominal pressure, including with the straight leg raise maneuver during HRM, increased the recognition of transient or intermittent hiatus hernia that associated with abnormal reflux burden (14). Our findings suggest that recognition of an intermittent hernia has similar reflux implications as a persistent hernia, with similar management implications (1).…”

Esophageal motor abnormalities in gastroesophageal reflux disorders

“…The straight leg raise (SLR) maneuver, designed to create a scenario resembling EGJ outflow obstruction by increasing intra-abdominal pressure, has been recently proposed to evaluate the integrity of the EGJ during HRM[ 69 , 70 , 71 ]. Rogers et al .…”

“…Furthermore, they observed that an increase in peak intra-esophageal pressure of ≥100% during SLR is associated with pathologic GERD[ 70 ]. Moreover, even in patients considered to have a normal EGJ structure based on standard HRM investigation criteria, the identification of transient hiatal separation induced by SLR can predict acid reflux burden, particularly in the context of IEM[ 71 ]. In addition, performing SLR during HRM while measuring the impedance value of the CSI can enhance the ability to identify GERD due to the better mucosal contact with impedance sensors[ 68 ].…”